Health inspection·July 25, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to immediately inform the resident representative(s) when there was- A significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications or Resident #1. The facility failed to ensure LVN A notified the residents representative when Resident #1 was sent to the ER (Emergency Room) after a change in condition occurred during dialysis on 6/28/23. This failure placed residents at risk of a delay in resident representative involvement in care, and a worsening of their condition. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), and Acute on Chronic diastolic (congestive) Heart Failure. He had a BIMs of 15 (cognitively intact). Resident #1 required limited to extensive assistance with ADLs. Oxygen usage while a resident and while not a resident was not indicated on the MDS. Record review of Resident #1's progress notes dated 6/27/23 at 1:28pm written by LVN B, revealed Resident #1 reported having SOB and the physician was notified. Oxygen was placed on the resident at 2 Liters. Record review of Resident #1's progress notes from 6/28/23 revealed there were no further progress notes input before, during or after the resident's discharge. Record review of Facility's Resident Availability record revealed Resident #1 was sent to dialysis at 7:30am on 6/28/23. No return was recorded after that entry. Record review of Resident #1's dialysis communication sheets revealed no communication sheet was available for 6/28/23. Record review of Resident #1's Discharge summary dated [DATE] at 5:00pm revealed the reason for discharge was the resident was sent to the hospital from dialysis. Record review of Resident #1's Acute Care Hospital emergency room Clinical Report dated 6/28/23 Page 1 of 10 676335 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed he was admitted on [DATE] at 10:48 am with a chief complaint of dyspnea (difficulty breathing). That started 2 days ago; Patient was taken to dialysis with an empty oxygen tank. He was picked up from dialysis by EMS (emergency medical services) due to dyspnea. Record review of Resident #1's Dialysis Center Patient Notes dated 6/28/23 at 12:03pm revealed he arrived Resident #1 arrived at around 8:40pm with oxygen in place but visibly short of breath and having trouble catching his breath. Dialysis Center RN C discovered that portable oxygen tank was empty and Resident #1's oxygen saturation was 84%. He was placed on oxygen with a concentrator and his oxygen improved to 96%. After dialysis was attempted, he continued to be visibly short of breath and started complaining of chest pain. Dialysis was ended, and RN C sent him to the ER for evaluation. RN C called the Facility and notified them of transfer to ER due to SOB. Interview on 7/25/23 at 12:43pm with Resident #1 revealed on 6/28/23 he felt breathless, while at dialysis. He stated he felt he needed oxygen and was not sure why he was not getting any from the oxygen tank and felt it was not working or ran out of oxygen. He stated he alerted the Dialysis Center staff and they brought him to the back and started helping him. He ended up going to the Acute Care Hospital emergency room. He was sent to the emergency room within 1 hour of leaving the Facility. He cannot recall if the nurse gave him a full tank of oxygen before leaving the Facility. Interview with the Dialysis Center Administrator on 7/25/23 at 1:37pm, revealed that on 6/28/23, Resident #1 was transported to the Dialysis Facility and brought to the lobby while he awaited his chair to be ready. Shortly after he arrived, he started to complain of SOB, a nurse checked his oxygen levels, and it was low at 84%. This was when it was realized the oxygen tank, he was transported with, was empty. He was immediately brought back and hooked up to Dialysis Center oxygen at 8:40am and his oxygen saturation recovered to 96%. The Resident's dialysis was attempted for 25 minutes, and the resident remained unwell, so it was decided to send him to an Acute Care Hospital. Interview and record review with LVN A on 7/25/23 at 5:11pm revealed on 6/28/23 he helped get Resident #1 on oxygen before he left to dialysis. He stated he got the tank off the charging station and believed it was full. He stated once he was moved from the oxygen concentrator to the tank the resident complained the tank was not working properly. LVN A provided teaching to the resident that he needed to take a breath for the oxygen to be delivered. He stated there should be a progress note stating the resident's condition before going to dialysis. He stated there should be a dialysis communication sheet for 6/28/23 as well. LVN A reviewed the Physician Order List and revealed there was no order for oxygen administration or parameters. He stated there should be a standing order for oxygen. LVN A reviewed Progress Notes and revealed there was no progress notes before going to dialysis. He could not recall why and stated there should be. He said he did not notify Resident #1's family when he didn't return to the Facility. He said the risks of not documenting properly were the next person not knowing what happened. The risks of not having proper oxygen could be respiratory failure. Interview and record review with the DON on 7/25/23 at 7:44pm revealed progress notes would be found in the electronic medical record. Her expectation was that they would include the time and condition the resident was in at the time they left the Facility. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. She stated she did not attempt to communicate with dialysis center because LVN A received a call around 10:30am to 12:00pm that he was sent to ER for unknown reason. She did not call the Acute Care Hospital or Resident #1's family. She stated Facility did not have the Dialysis communication sheet from 6/28/23, she stated she didn't think to ask for it back. The Dialysis center didn't return the communication book back to them despite it being a part of Resident #1's 676335 Page 2 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical records. She stated that all residents have a standing order for oxygen administration. Resident #1's progress notes reviewed and revealed no documentation on 6/28/23 in residents' electronic medical records. Resident #1's Physician Order Lists also reviewed and no standing order for oxygen administration was available. The Dialysis Communication sheet was also reviewed, and DON stated they do not have it. Interview with Administrator on 7/25/23 at 8:10pm revealed that the Resident Availability Record and vital signs record was their documentation that Resident #1 was properly assessed before leaving the Facility. Interview with Resident #1's FM 1 on 7/26/23 at revealed 10:25am revealed she was not notified of Resident #1s transfer from dialysis to the Acute Care Hospital. She was also unaware of why Resident #1 needed oxygen; he did not use oxygen at baseline. She stated there was no communication between the Facility and herself and or her FM 2 during the time Resident #1 was at the Facility. Interview with Resident #1's FM 2 on 7/26/23 at 11:19am revealed Resident was sent to Acute Care Hospital after he was sent to dialysis with an empty oxygen tank. FM 2 stated that the drive from the Facility to the Dialysis Center was about 30 minutes and he was not sure why the tank ran out so fast. He was not informed of Resident #1's hospitalization, or why he was sent with an empty oxygen tank to dialysis. He stated he made several calls before finding him in the Acute Care Hospital where he ended up being admitted for 2 or 3 days. He was not on oxygen at baseline, and he was unsure why he suddenly required oxygen. Record Review of facility policy named Change in a Resident's Condition or Status revised May 2017 revealed the nurse will notify the residents Attending Physician when there has been a significant change in the residents physical/emotional/mental condition, need to transfer the resident to a hospital/treatment center, discharge without proper medical authority. A significant change is described as a major decline or improvement that would not resolve without intervention by staff. It also revealed a nurse will notify the resident's representative when transferred to a hospital/treatment center, a decision has been made to discharge the resident, and for a significant change unless otherwise instructed not to 676335 Page 3 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety Resident #1. The facility failed to ensure LVN A performed the proper assessment while caring for a resident during oxygen administration and ensure oxygen equipment was in working order. This failure could place residents at risk of not being monitored or assessed properly along with not receiving the proper amount of oxygen which could lead to worsening of residents' condition. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), and Acute on Chronic diastolic (congestive) Heart Failure. He had a BIMs of 15 (cognitively intact). Resident #1 required limited to extensive assistance with ADLs. Oxygen usage while a resident and while not a resident was not indicated on the MDS. Record review of Resident #1s Physician Order List dated 6/19/23 revealed no standing order for oxygen administration. Record review of Resident #1's progress notes dated 6/27/23 at 1:28pm written by LVN B, revealed Resident #1 reported having SOB and the physician was notified. Oxygen was placed on the resident at 2 Liters. Record review of Resident #1's handwritten Physician Telephone Order dated 6/27/23. It read oxygen at 2-4 Lpm via N/C (nasal cannula) as needed to maintain O2 (oxygen) above 92% or for noted SOB. The order had the following missing information: Resident #1's date of birth , room number, attending physician, time ordered, notification of the above treatment change, time receiving order and date of physician signature. Record review of Resident #1's progress notes from 6/28/23 revealed there were no further progress notes input before, during or after the resident's discharge. Record review of Resident #1's Vital Signs Grid on 6/28/23 revealed vitals were entered at 7:27am, 7:46am, and 11:48am, no indication of oxygen use was noted in the note's column on the grid. Record review of Facility's Resident Availability record revealed Resident #1 was sent to dialysis at 7:30am on 6/28/23. No return was recorded after that entry. Record review of Resident #1's dialysis communication sheets revealed no communication sheet was available for 6/28/23. Record review of Resident #1's Discharge summary dated [DATE] at 5:00pm revealed the reason for discharge was the resident was sent to the hospital from dialysis. 676335 Page 4 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Acute Care Hospital emergency room Clinical Report dated 6/28/23 revealed he was admitted on [DATE] at 10:48 am with a chief complaint of dyspnea (difficulty breathing). That started 2 days ago; Patient was taken to dialysis with an empty oxygen tank. He was picked up from dialysis by EMS (emergency medical services) due to dyspnea. Record review of Resident #1's Dialysis Center Patient Notes dated 6/28/23 at 12:03pm revealed he arrived Resident #1 arrived at around 8:40pm with oxygen in place but visibly short of breath and having trouble catching his breath. Dialysis Center RN C discovered that portable oxygen tank was empty and Resident #1's oxygen saturation was 84%. He was placed on oxygen with a concentrator and his oxygen improved to 96%. After dialysis was attempted, he continued to be visibly short of breath and started complaining of chest pain. Dialysis was ended, and RN C sent him to the ER for evaluation. RN C called the Facility and notified them of transfer to ER due to SOB. Interview on 7/25/23 at 12:43pm with Resident #1 revealed on 6/28/23 he felt breathless, while at dialysis. He stated he felt he needed oxygen and was not sure why he was not getting any from the oxygen tank and felt it was not working or ran out of oxygen. He stated he alerted the Dialysis Center staff and they brought him to the back and started helping him. He ended up going to the Acute Care Hospital emergency room. He was sent to the emergency room within 1 hour of leaving the Facility. He cannot recall if the nurse gave him a full tank of oxygen before leaving the Facility. Interview on 7/25/23 at 1:06pm with the DON revealed the portable oxygen tank was a new system where they could be refilled in house. The station was found in the medication room, and they should be refilled by the nurses before they send a resident anywhere outside of the Facility. She stated when full they can last for 6 hours when being used at 2-6 liters. She stated the full tanks were stored in the oxygen room. Interview with the Dialysis Center Administrator on 7/25/23 at 1:37pm, revealed that on 6/28/23, Resident #1 was transported to the Dialysis Facility and brought to the lobby while he awaited his chair to be ready. Shortly after he arrived, he started to complain of SOB, a nurse checked his oxygen levels, and it was low at 84%. This was when it was realized the oxygen tank, he was transported with, was empty. He was immediately brought back and hooked up to Dialysis Center oxygen at 8:40am and his oxygen saturation recovered to 96%. The Resident's dialysis was attempted for 25 minutes, and the resident remained unwell, so it was decided to send him to an Acute Care Hospital. Interview and record review with LVN A on 7/25/23 at 5:11pm revealed on 6/28/23 he helped get Resident #1 on oxygen before he left to dialysis. He stated he got the tank off the charging station and believed it was full. He stated once he was moved from the oxygen concentrator to the tank the resident complained the tank was not working properly. LVN A provided teaching to the resident that he needed to take a breath for the oxygen to be delivered. He stated there should be a progress note stating the resident's condition before going to dialysis. He stated there should be a dialysis communication sheet for 6/28/23 as well. LVN A reviewed the Physician Order List and revealed there was no order for oxygen administration or parameters. He stated there should be a standing order for oxygen. LVN A reviewed Progress Notes and revealed there was no progress notes before going to dialysis. He could not recall why and stated there should be. He stated he received an in-service training within the last two months (May or June 2023) on how to properly use the oxygen tanks. He said the risks of not documenting properly were the next person not knowing what happened. The risks of not having proper oxygen could be respiratory failure. Interview and record review with the DON on 7/25/23 at 7:44pm revealed progress notes would be 676335 Page 5 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few found in the electronic medical record. Her expectation was that they would include the time and condition the resident was in at the time they left the Facility. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. She stated she did not attempt to communicate with dialysis center because LVN A received a call around 10:30am to 12:00pm that he was sent to ER for unknown reason. She did not call the Acute Care Hospital or Resident #1's family. She stated Facility did not have the Dialysis communication sheet from 6/28/23, she stated she didn't think to ask for it back. The Dialysis center didn't return the communication book back to them despite it being a part of Resident #1's medical records. She stated that all residents have a standing order for oxygen administration. Resident #1's progress notes reviewed and revealed no documentation on 6/28/23 in residents' electronic medical records. Resident #1's Physician Order Lists also reviewed and no standing order for oxygen administration was available. The Dialysis Communication sheet was also reviewed, and DON stated they do not have it. Interview with Administrator on 7/25/23 at 8:10pm revealed that the Resident Availability Record and vital signs record was their documentation that Resident #1 was properly assessed before leaving the Facility. Interview with Resident #1's FM 1 on 7/26/23 at revealed 10:25am revealed she was not notified of Resident #1s transfer from dialysis to the Acute Care Hospital. She was also unaware of why Resident #1 needed oxygen; he did not use oxygen at baseline. She stated there was no communication between the Facility and herself and or her FM 2 during the time Resident #1 was at the Facility. Interview with Resident #1's FM 2 on 7/26/23 at 11:19am revealed Resident was sent to Acute Care Hospital after he was sent to dialysis with an empty oxygen tank. FM 2 stated that the drive from the Facility to the Dialysis Center was about 30 minutes and he was not sure why the tank ran out so fast. He was not informed of Resident #1's hospitalization, or why he was sent with an empty oxygen tank to dialysis. He stated he made several calls before finding him in the Acute Care Hospital where he ended up being admitted for 2 or 3 days. He was not on oxygen at baseline, and he was unsure why he suddenly required oxygen. Record Review of facility policy named Oxygen Administration revised October 2010 revealed after completing oxygen set up or adjustment record in residents medical record the date/time the procedure was performed, the rate of oxygen flow, route, and rationale, the reason for p.r.n administration, and all assessment data obtained before, during, and after procedure. 676335 Page 6 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, on each resident that are- complete; accurately documented; readily accessible; and, systematically organized for 1 of 2 residents (Resident #1). The facility failed to maintain medical records for Resident #1's progress notes, telephone order, and dialysis communication sheet from 6/28/23 that were complete and accurate. This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), and Acute on Chronic diastolic (congestive) Heart Failure. He had a BIMs of 15 (cognitively intact). Resident #1 required limited to extensive assistance with ADLs. Oxygen usage while a resident and while not a resident was not indicated on the MDS. Record review of Resident #1s Physician Order List dated 6/19/23 revealed no standing order for oxygen administration. Record review of Resident #1's progress notes dated 6/27/23 at 1:28pm written by LVN B, revealed Resident #1 reported having SOB and the physician was notified. Oxygen was placed on the resident at 2 Liters. Record review of Resident #1's handwritten Physician Telephone Order dated 6/27/23. It read oxygen at 2-4 Lpm via N/C (nasal cannula) as needed to maintain O2 (oxygen) above 92% or for noted SOB. The order had the following missing information: Resident #1's date of birth , room number, attending physician, time ordered, notification of the above treatment change, time receiving order and date of physician signature. Record review of Resident #1's progress notes from 6/28/23 revealed there were no further progress notes input before, during or after the resident's discharge. Record review of Resident #1's Vital Signs Grid on 6/28/23 revealed vitals were entered at 7:27am, 7:46am, and 11:48am, no indication of oxygen use was noted in the notes column on the grid. Record review of Facility's Resident Availability record revealed Resident #1 was sent to dialysis at 7:30am on 6/28/23. No return was recorded after that entry. Record review of Resident #1's dialysis communication sheets revealed no communication sheet was available for 6/28/23. Record review of Resident #1's Discharge summary dated [DATE] at 5:00pm revealed the reason for discharge was the resident was sent to the hospital from dialysis. 676335 Page 7 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Acute Care Hospital emergency room Clinical Report dated 6/28/23 revealed he was admitted on [DATE] at 10:48 am with a chief complaint of dyspnea (difficulty breathing). That started 2 days ago; Patient was taken to dialysis with an empty oxygen tank. He was picked up from dialysis by EMS (emergency medical services) due to dyspnea. Record review of Resident #1's Dialysis Center Patient Notes dated 6/28/23 at 12:03pm revealed he arrived Resident #1 arrived at around 8:40pm with oxygen in place but visibly short of breath and having trouble catching his breath. Dialysis Center RN C discovered that portable oxygen tank was empty and Resident #1's oxygen saturation was 84%. He was placed on oxygen with a concentrator and his oxygen improved to 96%. After dialysis was attempted, he continued to be visibly short of breath and started complaining of chest pain. Dialysis was ended, and RN C sent him to the ER for evaluation. RN C called the Facility and notified them of transfer to ER due to SOB. Interview on 7/25/23 at 12:43pm with Resident #1 revealed on 6/28/23 he felt breathless, while at dialysis. He stated he felt he needed oxygen and was not sure why he was not getting any from the oxygen tank and felt it was not working or ran out of oxygen. He stated he alerted the Dialysis Center staff and they brought him to the back and started helping him. He ended up going to the Acute Care Hospital emergency room. He was sent to the emergency room within 1 hour of leaving the Facility. He cannot recall if the nurse gave him a full tank of oxygen before leaving the Facility. Interview on 7/25/23 at 1:06pm with the DON revealed the portable oxygen tank was a new system where they could be refilled in house. The station was found in the medication room, and they should be refilled by the nurses before they send a resident anywhere outside of the Facility. She stated when full they can last for 6 hours when being used at 2-6 liters. She stated the full tanks were stored in the oxygen room. Interview with the Dialysis Center Administrator on 7/25/23 at 1:37pm, revealed that on 6/28/23, Resident #1 was transported to the Dialysis Facility and brought to the lobby while he awaited his chair to be ready. Shortly after he arrived, he started to complain of SOB, a nurse checked his oxygen levels, and it was low at 84%. This was when it was realized the oxygen tank, he was transported with, was empty. He was immediately brought back and hooked up to Dialysis Center oxygen at 8:40am and his oxygen saturation recovered to 96%. The Resident's dialysis was attempted for 25 minutes, and the resident remained unwell, so it was decided to send him to an Acute Care Hospital. Interview and record review with LVN A on 7/25/23 at 5:11pm revealed on 6/28/23 he helped get Resident #1 on oxygen before he left to dialysis. He stated he got the tank off the charging station and believed it was full. He stated once he was moved from the oxygen concentrator to the tank the resident complained the tank was not working properly. LVN A provided teaching to the resident that he needed to take a breath for the oxygen to be delivered. He stated there should be a progress note stating the resident's condition before going to dialysis. He stated there should be a dialysis communication sheet for 6/28/23 as well. LVN A reviewed the Physician Order List and revealed there was no order for oxygen administration or parameters. He stated there should be a standing order for oxygen. LVN A reviewed Progress Notes and revealed there was no progress notes before going to dialysis. He could not recall why and stated there should be. He said the risks of not documenting properly were the next person not knowing what happened. The risks of not having proper oxygen could be respiratory failure. Interview and record review with the DON on 7/25/23 at 7:44pm revealed progress notes would be found in the electronic medical record. Her expectation was that they would include the time and 676335 Page 8 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition the resident was in at the time they left the Facility. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. She stated she did not attempt to communicate with dialysis center because LVN A received a call around 10:30am to 12:00pm that he was sent to ER for unknown reason. She did not call the Acute Care Hospital or Resident #1's family. She stated Facility did not have the Dialysis communication sheet from 6/28/23, she stated she didn't think to ask for it back. The Dialysis center didn't return the communication book back to them despite it being a part of Resident #1's medical records. She stated that all residents have a standing order for oxygen administration. Resident #1's progress notes reviewed and revealed no documentation on 6/28/23 in residents' electronic medical records. Resident #1's Physician Order Lists also reviewed and no standing order for oxygen administration was available. The Dialysis Communication sheet was also reviewed, and DON stated they do not have it. Interview with Administrator on 7/25/23 at 8:10pm revealed that the Resident Availability Record and vital signs record was their documentation that Resident #1 was properly assessed before leaving the Facility. Interview with Resident #1's FM 1 on 7/26/23 at revealed 10:25am revealed she was not notified of Resident #1s transfer from dialysis to the Acute Care Hospital. She was also unaware of why Resident #1 needed oxygen; he did not use oxygen at baseline. She stated there was no communication between the Facility and herself and or her FM 2 during the time Resident #1 was at the Facility. Interview with Resident #1's FM 2 on 7/26/23 at 11:19am revealed Resident was sent to Acute Care Hospital after he was sent to dialysis with an empty oxygen tank. FM 2 stated that the drive from the Facility to the Dialysis Center was about 30 minutes and he was not sure why the tank ran out so fast. He was not informed of Resident #1's hospitalization, or why he was sent with an empty oxygen tank to dialysis. He stated he made several calls before finding him in the Acute Care Hospital where he ended up being admitted for 2 or 3 days. He was not on oxygen at baseline, and he was unsure why he suddenly required oxygen. Record review of facility policy named Charting and Documentation revised July 2017 revealed the following information is to be documented in the residents medical record: objective observations, medication administration, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the residents, and progress or changes in the care plan goals and objectives. It should also be complete and accurate. The policy continues to say that procedures and treatment will include care-specific details including date and time procedure/treatment was provided, the assessment date and any unusual findings, notification of family, etc. Record Review of facility policy named Change in a Resident's Condition or Status revised May 2017 revealed the nurse will notify the residents Attending Physician when there has been a significant change in the residents physical/emotional/mental condition, need to transfer the resident to a hospital/treatment center, discharge without proper medical authority. A significant change is described as a major decline or improvement that would not resolve without intervention by staff. It also revealed a nurse will notify the resident's representative when transferred to a hospital/treatment center, a decision has been made to discharge the resident, and for a significant change unless otherwise instructed not to. Record Review of facility policy named Oxygen Administration revised October 2010 revealed after completing oxygen set up or adjustment record in residents medical record the date/time the procedure 676335 Page 9 of 10 676335 07/25/2023 Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032

F 0842 was performed, the rate of oxygen flow, route, and rationale, the reason for p.r.n administration, and all assessment data obtained before, during, and after procedure. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676335 Page 10 of 10